Have you ever had a day so stressful that you walked away with a headache? Conversely, have you ever had a headache come on at an inconvenient time that caused you stress?

The relationship between stress and pain is complex. As stress and pain are seemingly two sides of the same coin, the research into their relationship is ample. However, there is still a lot that is unknown.

For now, let’s look at how and why stress should be addressed for anyone seeking physical therapy for their pain.

Pain, or more specifically chronic pain, “is a pathology afflicting 20%-30% of adults…and almost half of pain suffering adults do not achieve adequate pain management” (Abdallah & Geha, 2017). It is the number one reason that people, ultimately, seek physical therapy. Understandably so.

We all know that long-term stress negatively impacts the body. You’ve heard it, or maybe even experienced it, before. Chronic pain can be just as detrimental. After all, pain is also a stressor. However, “…stress is rarely addressed in pain rehabilitation” (Hannibal & Bishop, 2014).

So, if stress causes pain and pain causes stress it’s easy to see how we might get stuck in a loop of maladaptive responses that, over time, can lead to further issues, like depression and anxiety.

Before we go farther, let’s take a look at how stress works.

The Stress Response

There is no such thing as a stress free life. From the minute we’re born stress is an irrevocable part of our existence. In fact, stress is not the enemy we make it out to be. We need stress and the physiological and psychological responses to stress for our survival, or we did thousands of years ago.

When we acknowledge a threat, whether real or imagined, our bodies react. Our nervous system shifts and our brains and hormones are primed for fight or flight.

When our sympathetic nervous system kicks into gear, we have two different types of reactions, a fast response and a slow response. Our fast response involves our sympathetic-adreno-medullar axis and the secretion of the hormones,  norepinephrine and epinephrine. The secretion of these hormones and their interactions with different protein receptors in the body results in, contraction of smooth and cardiac muscles cells leading to vasoconstriction, increased blood pressure,heart rate, cardiac output, skeletal muscle blood flow,  increased sodium retention,  increased glucose levels (due to glycogenolysis and gluconeogenesis), lipolysis, increased oxygen consumption, and thermogenesis. It also leads to reduced intestinal motility, cutaneous vasoconstriction, bronchiolar dilatation. In addition, SAM activation cases behavioral activation (enhanced arousal, alertness, vigilance, cognition, focused attention, and analgesia)” (Chu et al., 2022). Essentially it primes us to fight off danger or prepares us to run from it.

Our slow response involves our hypothalamus-pituitary-adrenal axis and the secretion of cortisol. “Glucocorticoid hormones such as cortisol, corticosterone, and dexamethasone have various effects of conserving energy and maintaining energy supply such as reduction of inflammation, restriction of growth, production of energy, removal of unnecessary or malfunctioning cellular components” (Chu et al., 2022).

Cortisol

Despite the fact that we aren’t being chased down the streets by lions, tigers or bears…or maybe you are…what you do on a Friday night is your own thing…the stress response is still innately wired within us though now it is triggered by exams, deadlines, daycare drop offs, divorce, disease, etc. And now, more than ever, our stress responses are in overdrive. There is very little reprieve.

This chronic stress is what causes issues. The constant triggering of cortisol secretion eventually leads to cortisol dysfunction or the depletion or cortisol altogether and, thus, we find ourselves at a greater risk for disease and disorders, including increased pain.

When cortisol fails to function properly we end up with an unmodulated inflammatory response (cortisol is a potent anti-inflammatory that our bodies release to combat the pro-inflammatory byproducts that are released during the first phase of the stress response). As a result, we experience or are subject to:

• oxidative and nitrosative stress
• free radical damage
• cellular death
• aging
• systemic tissue degeneration
• bone and muscle breakdown
• fatigue
• depression
• pain
• memory impairment
• sodium-potassium dysregulation
• orthostatic hypertension
• impaired pupillary light reflex
• potential susception to 100s of idiopathic inflammatory autoimmune diseases

Pain

There is still so much to be learned when it comes to pain and how we perceive it. How our bodies process and feel pain is a complex series of signals and responses. Additionally, the concept of pain is made all the more complicated by its subjective nature. What one person perceives as a mild irritant might be experienced by another as excruciating pain because “the amount of pain perceived by a person is governed not only by the amount of tissue injury present but also by emotional and psychologiical factors” (Ahmad & Zakaria, 2015).

Stress & Pain

Both stress and pain are subjective. The emotional and psychological state/background of a person weighs heavily on a person’s experience of either. As with pain, what is mildly irritating for one person could be a tremendous stressor for another (like public speaking). Furthermore, stress and pain both involve similar bodily systems. Both involve the central nervous system, which signals chemical releases in the body. Both involve very specific brain systems that lean on hippocampal function to provide context for the current event (memories of past pain or trauma can magnify stress or pain in a current situation). In fact, “maladaptive cognitive appraisals or beliefs regarding the threatening nature of potential stressors may promote an exaggerated physiologic stress response that is likely to initiate, exacerbate or prolong the pain experience” (Hannibal & Bishop, 2014).

All of that to say, the link between stress and pain is, at its most basic level, very intimately linked. So it makes sense that stress could play a role in heightened pain response and vice versa.

Ultimately

“The overall literature suggests that exaggerated psychological responses to acute pain are maladaptive and likely to intensify the pain experience and impede recovery”, particularly psychological responses to emotions like fear or catastrophizing (Hannibal & Bishop, 2014).

So, what does this mean? It means that if you are a person with acute or chronic pain, it is worth it to consider your recent stress levels when planning your path to recovery. Incorporating common stress management practices, such as meditation, yoga, walks, epsom salt baths, etc, into your rehabilitation. The best case scenario is a reduction in pain and speedy recovery. Worst case scenario? You spent 20 minutes in downward dog and increased your flexibility or you wasted a bathtub’s worth of water and a cup of your best bath salts.

What this means for manual therapy practitioners is that stress levels must be addressed upon intake and assessment. As the relationship between stress and pain is increasingly elucidated, we need to acknowledge that answers lie not only in our clients’ tissue but also in their emotional/mental wellbeing as well.

If you’re interested in learning more about how you can manage your pain with exercise, diet and manual therapy, don’t hesitate to reach out!

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References:

Abdallah, C. G., & Geha, P. (2017). Chronic pain and chronic stress: Two sides of the same coin? Chronic Stress. https://doi.org/10.1177/2470547017704763

Ahmad, A. H., & Zakaria, R. (2015, December). Pain in times of stress. The Malaysian journal of medical sciences : MJMS. Retrieved April 4, 2023, from https://pubmed.ncbi.nlm.nih.gov/27006638/

Chu, B., Marwaha, K., Sanvictores, T., & Ayers, D. (2022, September 12). Physiology, stress reaction. National Center for Biotechnology Information. Retrieved April 7, 2023, from https://pubmed.ncbi.nlm.nih.gov/31082164/

Hannibal, K. E., & Bishop, M. D. (2014). Chronic stress, cortisol dysfunction, and pain: A psychoneuroendocrine rationale for stress management in pain rehabilitation. Physical Therapy, 94(12), 1816–1825. https://doi.org/10.2522/ptj.20130597